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HomeMy WebLinkAbout4.0 Condition of ApprovalForm vo OFFICE OF THE STATE ENGINEER GWS25 COLORADO DIVISION OF WATER RESOURCES 818 Centennial Bldg 1313 Sherman St Denver Colorado 80203 3038663581 APPLICANT LIC WELL PERMIT NUMBER 74762 F DIV 5 WD 38 DES BASIN MD Lot 3 Block Filing Subdiv RIES EXEMPTION 1 2 3 4 5 6 7 8 9 10 APPROVED WELL LOCATION GARFIELD COUNTY 14 SW 14 Section 31 Township 7 S Range 87 W Sixth PM DISTANCES FROM SECTION LINES Ft from Section Line Ft from Section Line UTM COORDINATES MetersZone13NAD83 Easting Northing ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT CONDITIONS OF APPROVAL BRANDEN COHEN 11258 HIGHWAY 133 CARBONDALE CO 81623 970 3612195 f TO CONSTRUCT A WELL This well shall be used in such a way as to cause no material injury to existing water rights The issuance of this permit does not ensure that no injury will occur to another vested water right or preclude another owner of a vested water right from seeking relief in a civil court action The construction of this well shall be in compliance with the Water Well Construction Rules 2 CCR 4022 unless approval of a variance has been granted by the State Board of Examiners of Water Well Construction and Pump Installation Contractors in accordance with Rule 18 Approved pursuant to CRS 37901372 for the construction of a well appropriating ground water tributary to the Roaring Fork River on the condition that the well shall be operated only when the Basalt Water Conservancy DistricYs substitute water supply plan approved by the State Engineer is in effect and when a water allotment contract between the well owner and the Basalt Water Conservancy District for the release of replacement water from Ruedi Reservoir is in effect or under an approved plan for augmentation BWCD contract 77 Approved as a well on a residential site of 256 acres described as lot 3 Ries Exemption Garfield County The use of ground water from this well is limited to ordinary household purposes inside one 1 single family dwelling and the irrigation of not more than 5800 square feet 0133 of an acre of home gardens and lawns All use of this well wili be curtailed unless the water aliotment contract or a plan for augmentation is in effect This well is known as Ries Well no 3 The pumping rate of this well shall not exceed 15 GPM The average annual amount of ground water to be appropriated shall not exceed 070 acrefoot 228095 gallons The owner shall mark the well in a conspicuous place with well permit numbers name of the aquifer and court case numbers as appropriate The owner shall take necessary means and precautions to preserve these markings A totalizing flow meter must be installed on this well and maintained in good working order Permanent records of all diversions must be maintained by the well owner recorded at least annually and submitted to the Division Engineer upon request Pursuant to Rule 623 of the WaterWell Construction Rules the well construction contractor shall submit the asbuilt well location on work reports required by Rule 173 within 60 days of completion of the well The measured location must be accurate to 200 feet of the actual location The location information must include a GPS location UTM coordinates pursuant to the Division of Water Resources guidelines NOTE Expired permit nos 46669F and 64670F was previously issued for this lot NOTE Parcel Identification Number PIN 23239131300027 NOTE Assessor Tax Schedule Number R111790 APPROVED DMW State Enging Receiot No 9503428 DATE ISSUED 01212011 2 o RATION DATE 0 COLORA00 DIVISION OF WATER RESOURCES DEPARTMENT OF NATURAL RESOURCES 1313 SHERMAN ST RM 818 DENVER CO 80203 phone info 303 8663587 main 303 8663581 fax 303 8663589 htt 1lwwwwaterstatecous RESIDENTIAL Note Also use this form to apply for livestock watering Water Well Permit Application Review form instructions prior to completing form The form must be completed in black or blue ink or typed 1 Applica Information l b c State Zipcode q e d3 lO lr 17 5 I 2 Type Of Application check applicable boxes Construct newwell Change source aquifer Replace existing well Reapplication expired permit Use exis6ng well Rooftop precip collection Change or increase use Other 3 Refer To if applicable Wetl permil WaterCourt case Gy7Q y Deslgnated Basn Determination Well name or 4 Location Of Pro osed Well Important See Instructions County C 2 o 4oe 4 Sec6on Township N or 5 Range E or W Prindpal Meridan 3I 37 sDistanceofweNfromseclionlinessectionlinesatetypicallynotpropertylines gcJ Ft irom N S jQp Ft trom E W For replacement wells oNy tlistarrce and direction Vom oldwell tonewwell feet direction Well location address Indude Glty Slate Zip Check ifwell address is same as in Item 1 OpNortal GPS well IocaAOninforma8on in UTM format GPS unitsettings are as fdlows Format must be UTM Zone 12 or p Zone 73 Easting Unilsmustbe Maters Datum must be NAD83 Northing Unit mustbe set lo Vue noAh Was GPSunit checked for above YES Rememberto set Datum to NAD83 5 Parcel On Which Well Will Be Located YOU MUST ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL A You must check and comp te one of the following Subdivision Name S X y pJ Lot Block FilingUnit County exemption attach copy of courrty approval survey Name Lot Parcel less than 35 acres not in a subdivision attach a deed with metes and bounds description recorded prior to June 1 1972 and a current deed Mining claim anacn a coPy o ue deea or survey Name Square 40 acre parcel as described in Item 4 PBfC@ Of 35 Of fT10f@ 8C2S attarh a metes and bounds descripfion or survey fh@f altach metes bounds descrSptio or survey and supporting dowmenls B of acres in parcel C Are you the owner of this parcelJYESNOifnoseeinstrucfions Will lhfs be Ihe on7y well on this parcel YES NO if no lisl olherwells Office Use Only Eu 18 11 1 Form GWSQ A 2 5 201 vTE STATE ENGINEER Qr93 3 4 6 Use O echeck applicable boxes Se ns to determine uses for which you may qualifyeAOrdinaryhouseholduseinonesinglefamilydwellingnooutsideuse B Ordinary household use in 1 to 3 singlefamily dwellings Number of dwellings Home gardeNlawn irrigation not to exceed one acre area irrigated sq ft acre Domestic animal watering noncommercial C Livestock watering on farmranchrangepasture 7 Well Data proposed Madmum pumping rate Mnual amount to be withdrawnl9Pm7d feet I 8 Water Supplier Is this parcel within boudaries of a water service area If yes provide name of supplier 9 Type Of Se S Septic tank absorption leach field Central system District name Vault Location sewage to be hauled to Other attach copy of engineering design and report 10 Proposed Well Driller License option acrefeet 11 Signature Of Applicants Or Authorized Agent The making of false statements herein constitutes perjury in the second degree which is punishable as a class 1 misdemeanor pursuant to CRS 244104 13a I have read the statements herein know the contents thereof andstate that the are true to m knowled e Sign here Must be original signature Date Print name 8 lltle 1 f fI5 CS liCJ OAJIC4d Office Use Only USGS mapname DWRmap no Surface elev xr Receipt area only l oFIP QGGQ iC t iSffi t i es LIUFc fs153rI7ctaiTirsArit 1Qf U AQUAMAP Q Z 8 IC UJ11T OOCj w Fx 3 23 f 3 oo Q2 7 WR ra X4 f 7 cwce cE La c TOPO MYLAR S85 DIV WD BA MD 77z Whitehead Dwight F From brandencohen branden@truenaturehealscom ent Wednesday January 19 2011 909AM A 2 5 2 fToWhiteheadDwight Subject Branden Cohen Well Permit Application r Ecs IW 19 11EF Hi Dwight WATER RESOURCESSTqTEENG1NEEigpleaseallowtomrubintosignmywellpermitapplicationonmybehalfGLENyyppp Thanks Branden Cohen Dwights number 9455665 x 5011 1 ccount Page 1 of 177 Account R111790 ioeto Parcel Number 239131300027 Situs Address 100 COLJNTY RD CATHERINE STORE RD City Carbondale Carbondale ZipCode 81623 81623 Tax Area O11 1RMF O11 Legal Summary Section 31 Township 7 Range 87 TR IN LT 12 AKA LOT 3 RIES EXEMPTION Transfers Owner Information Owner Name SELDMAN MARTIN L REINEKE KELLY RAE REVOCABLE TRUST Owner Address 166 SWINGING BRIDGE LANE BASALT CO 81621 Sale Price Sale Date 12032009 200 000 Tax Historv Tax Year Taxes 2010 2009 07082009 07O12009 OS152009 Images GIS 1082448 1084140 A12 5 201 Actutafl610 655000 Primary Taxable 189950 Tax Area O11 Mill Levy 569860 Type Actual Assessed Acres Land 655000 189950 2560 Doc Type 388 GWD GWD Book Page httpsactgarfieldcountycomassessortaxwebaccountj spaccountNumR 11179Q 1 192011 7 7 11Vhitehead Dwight From Melody Morris melody@resourceengcom Sent Friday January 21 2011 1127 AM To Whitehead Dwight A 2J 201 Subject 77 Chante Pejuta LLC Attachments greenip to chante pejuta Ilc 1 21 11pdf fvFifF itSCuiCE STAT ENGEEp Rrt Dwight attached is the billing records showing payment and the copy of the assignment and assignment fee that has been paid Unfortunately we do not have a calculation sheet in this file It is a really old contract and I guess one has never been done or at least put in the file I will see if Eric can do one for you Thank you Melody Morris Office Manager Resource Engineering Inc 970 9456777 Voice 970 9451137 Facsimile wwwresourceengcom The information contained in this email is PRIVILEGED AND CONFIDENTIAL information intended only for the use of the individual or entity named above If the reader of this message is not the intended recipient or the employee or agent responsible to deliver it to the intended recipient you are hereby notified that dissemination distribution or copying of this communication is strictly prohibited If you have received this communication in error please immediately notify us by telephone and delete the original message from your system Thank You Basat Water Conservancy District PO Box 974 Glenwood Springs CO 81602 970 9456777 T0 Gary Greenip arxl Mary Luciano 166 Swinging Bridge Lane Basalt CO 81621 F10 AN 2 5 01 41VATEF SitfF STAT EtGIr rn STATEMENT DATE 192011 Atqched to this statement is a breakdown of haw your bill was calculatl Please review Should you have any changss icluding change of address please indicate and return to us with ycur payment My questions conceming blEling please contact Melody Nlorris Resource Engineering Inc 9706777 DUE DATE ACCAUk1T AMOUNT DUE 124 2011 3357d 000 DATE DESCRIPTION AMOUNT BALANCE 12J311999 Balanoe forward 000 OSOl2007 Assignment Fee QuitiquitFrancis to GreenipLuciano 15Q00 iS000 05012007 2007 Contract Fee for the billing period 4i07 33i08 12500 27500 05152007 PNff 129330 Pitkin CLyTftle 27500 000 06J1020Q8 2008 Contrad Fe for the billing period 4i08 33109 13100 13100 070720Q8 PMT 402 13100 000 08042009 2009 Contract FPe for billing period 4109 331201Q 13600 13600 09042009 PMT 618 13600 000 08202010 2010 Contract fee for billing period 412010 3312011 14300 0 li042010 P 14300 000 30 DAYS PAST 3164 DAYS PAST 6190 DAYS PAST OVER 90 DAYS qEyOUNT DUE o00 o00 ooa o00 aaa oa StewatTtleCampanY i 2164pg 60outh8th Sfeet Suite 101 US BarkState Escraw count Carborldaf CQ 81623 DenverCaeo2o2 114201 so ooo AN 2 5 2011 Pay ForHundred Fifty and OOh00 Dollars WAEk itUU1G STAi ENGINE 45EAi Void aftar 90 days To te order of Basal Water Conservaricy Distrit PO Box 974 GlenrnioodSpringsC 8102 Fle g41094 Escrow Unit 281 Escrow Unit 281 Associated File Number File 94t094 Saes Representative Buyer Chante Pejuta LLC Seller Mary S Luaarw Martin L 5eldman and Kally R Reineke Revocable Trust Escrow Officer Mary L Scheurich Properly Address TBD County Road 100 Carbondale CO 81623 Legal Description Loi 3 Ries Exemptian i305 Assignment Fee 45000 Iji 5 5 4 2816219 1142011 450OQ ASSIGNMENT QF ALLOTMENT CONTRACT NO 77e BASALT WATER C4NSERVANCY DISTRICT Cll JAN 2 5 2011 JVA7ER trivstESTA7ENGtNEEtp FOR VALUE RECEIVED Mary S Luciano Assignor hereby sells assigns transfers and sets over to Chante Pejuta LLC a Colorado krnited liabiiity coznpany Assignee ail of Assignors right title and interesf in and to thaE certain Water Allotmene Contract with the Basalt Water Conservancy Distrit dated ctober 12 1987 which Conixact allots 0033 cuhic feet af water per second from the Districts direct flow rights and 07 acre feet of water per year of sfarage andor otlter augrnentaHon water owned or controlled by the District for use on khat reaE pxoperty desribed in Exhibit B attached hereto and incorporated herein by this reference This Assignment is conditianed upon the consent thereto by the Basalt Water Conservancy District as herein belov provied Assignee hereby assumes and agrees to pay and perform all of the obligaHans of the Ailattee under said Contract This Assignment shal be effective upon Assignors conveyance oE the above described property to Assignee Dated this day of vr 201 r r Assignees Mailing Address 1725 Highway x33 Carbondale CO 81623 Te2ephone Number jb f3 1 5 ASSIGNEE CHANTE PEJUTA LLC a Cotarada imited li i company B Name Tite ju L Assignrnent No 77c I Tary S LucialioClurnfe Pejuta LLC ri AI 2 201y EXHIBIT A TO ASSIGNMENT BASALT WATER CONSRVANCY DISTRICT CONTFtkCT vvArt Jc TAT E9VGIME rn The Assignment to which this Exhibit is attached and nnade a part of is approved and nnade subject ta the following eonditions 1 By acceptance of this Contract Assignee acknowledges this contract is included within a pending plan for augmentation Case No QICW305 intended to confirm Assignees right to utilize the water allotted hereunder at the Iocation and for the purposes hereinabove set forth Should this cantract not be included wzthin the Einal detree of court entered in Case No 01CW305 then Assignee acknowtedges that within two years of the date hereof or such tater date as the District may approve the Assignee shall file with the Watex Court of Water Divisian No 5 a water zights plan of augmentation for utalazation of water alZotted hereunder at the location and for the purposes hereinabove set forth or the Assignees water allotnnent as provided in this Contract may be included in another water rights plan of augmentation to be fited by the Distriet with the expenses thereof to be shared pzorata by the Contract holders included in such plan provided that inclusior oE the Assignees water allotment in he Districts plan of augmentaion shall be at the Districts sole discretion As a condiHon of having the District include the Assignees water aliotment ii1 the Districts Application for a plan of augmentation Assignee will provide such inforrnation and assistance including testirnony as may be needed for judicial approval of the plan The District makes no warranty that it will secure approval of the plan The Distrit may estabiish an augmentation piati fee to be paid by the holder of any Contract or amended Contract tobe included within a plan af augmentation to be filed by the District which fee shal be payable in advance of the inclusion of such Contract in a District plan of augmentation and may be based on the Districts good faith estimate of the anticipated expense of such plan of augmentation If such augmentation pan fee paid by a Contract halder exceeds the Contract holders prorata portion of the actual expenses inurred by ti District in cvmpleting said plan of augmentation the Disfrict shall refund such excess to the Contract holder Colversely if such augmentation plan fee paid by fhe Contract liolder does not cover the Contract holders prorata portian of the actual expenses incurred by the District in completing said plan of augmentation then Assignee shall pay the remazning balance of i ts poron of the actual expenses upon the Distriets providing the holder wirh a statement for the same To fhe extent that the District is caused additional costs because of objecHons filed specificalEy due to the incIusion of Assignees Contract in the filing such additionai rosts rnay be charged specifically to Assignee and not shareci on a prorata basis by all Contractees Assignment No 77e Mary S LucinnoChanle Pejufa LLC 3 1Et JAIV 2 5 201 FiVlTEk 4SUi1siCES STAl ENGNE r 2 Any and alI conditions impased upon the release and diversion of water allotted hereunder in any waterrights plan of augmentation or other water righs decree oE the Water CoUrt for Water Division No 5 shall be incarporated herein as a condition of approval af this contract Granting of this aliotment contract does not canstitute the Districts representation that the Assignee will receive a well permit or water rights decree for the land ta be benefitted hereby 3 In lieu of recording the Water Allotrnent Contract or this Assignment a Memorandum of Water Alotment Contract has been recorded with the Garfield County Clerk and Recorders Office on Fehrtary 31999 as Recepion No 539852 PAYMNT Assignee shall pay annualy for the uvater service described herein at a price to be fixed annually by the Baard of Directors of the District for such service Payment of the annual fee shall be nnade in fuIl within fifteen 15 days after the date of a notce from the District that the payment is due Said notice will advise the Assignee amang other things of the water delivery year to which the payment shall apply and the price which is applicabie to that year If a payment is not made by the due date a late fee of 50 or other amount as the Board nay set from time ta time will be assessed and finai written notice of the delinquent account and late ee assessment will be sent by the District to the Assignee at Assigrtees address set forth in the Assignment attached If payment is not made within thirty 30 cays after said finat written notice the District may at its option elect to terminate all oE the Assigztees right title or zntexest under this Contract in which event the water right allotted hereunder may be transferred leased or otherwise disposed of by the District at the discretion of its Board of Directors 5 WLL PEIVIIT f Assignee intends to divert through a well then Assignee must provide to District a copy of Assignees valid well pernlit before the District is obligated to deliver any water hereunder and it is the Assignees continuous duly to nrtaintain a valid well permit Assignee shall also ompIy with aiI restricions and limitations set forth in the well permit obtained from the Colorada Division f Water Resources Assignee must comply with the wellspacing requirements set forth in CRS 379a137 as amended if applicable Compliance with said sEatutory wellspacing rriteria shall be an express condition oE the extension o service hereunder and the District shall in no way be liable for an Assignees failure to camply Assignee ageees to mark the weEl in a conspicuous place with the permit number 6 MEASURING DEVIC OR METER Assignee agrees to provide at its own expense a totalizing flow meter with remote readout to continuausly and accurately measure at all imes al water diverted pursuant ta the terms of Assigmees water right and the Eerms of this Contract On or before November 15 of each year Assignee will provide accurate readings from such device or meter recorded on a manthly basis for the period i4ssigramerrt rVa 77e Man 5 LucirtnoChrtntc Pejutrr LLC 4 llr JAI 2 5 Ott vAflr itG TAi EPdGIVEFpai Novennber I through Octvber 30 of each year to DistriCt the Division Engineer and Water Corrmissioner Assignee acknowledges that failure to comply with this paragraph couid resUlt in legal actian to terminate Assignees dzversion of watez by the State of Colorado Division o Watez Resources By signing this Contract Assignee hereby speafically allows District through its authorized agent to enter upon Assignees property during ordinary business hours for the purpases af determining Assignees actual use of water 7 COMPLIANC W1TH SECTION 404 OF THE CLEAN WATER ACT Assignee shaII cornply with Section 404 of the Clean Watex Act and consult with the Army Corps of Engineers to romplete any Section 404 complaane that may be required as a result of the construction of any facilities necessary to use contract water 8 CONTRACT TERMLCTATION A Termination b District 1 The District may terminate thzs Contract far any vialation or breach of the terms of this Contract by Assignee or far Assignees breach of any other contract with the Distrxct 2 The District may terminate this Contract if in its discretian any judicial or administrarive proceedings initiated by Assignee threaten the Districts authority to onErat for delivery or use of the Districts water rights or threaten the Distxicts permits water rights or other interests flf the District Terminakion bv Assii 1 Assignee may terminate this Contract in its entirety Eor any reason by notifying the District in writing of the termination on or before April 1 Notice by said date will prevent the Assignees liability for the next annual contract charge Assirrrrerif No 77e Mnry S LuerRnvCfiante Pjutn LLC 5 AN 2 2011 aVAYEF tSViJiCES 5TA7 ENGIEFrn xxzsfT B LOT 3 A PAStCEL OP LAND SITUATED YN fAT 12 AND TdS NS14SSQ1t OY SECTION 1 TOWN5SIP 7 SOUTH RANGE 97 WEST OF TFiB SIYTH PRINCIFAL AIDI2t COVNTY Qy GARPZELD 9T1T8 QP COLORADOt SAID PARCSL 07 L11ND BEING MARS 7RfICQLAALY DBSCRIBED AS POLLOWSs COFSENCING AT TH8 SOlTFtWBST CORNSA OH S7lID SCTION 31s THEMCE N 19 DEGAIaE9 1 45 S 147135 PlET TO POINT OPI THE W85TEALY LINE OP SAID LOT 1Z S1YD POtT JLSO BEING ON THS NOATFIERL RICHY OT T9JY OF COiJN1Y ROAD N0 k00 A BENCE POST IN PIJ4CE TNSNC N 81 DEORLS 49 39 8 RLOHG SAID NpRTFiEALY RIGBS OP iQAY 54365 ABB THCNCE CONTINtlING ALONG 81I0 NORTiERLY RIGHS OP P7Y N 83 DEGRSES 14 S6 E 1837 PEE2 x0 TfTs TA178 @OItT OF BECIHNING TFENCE LItIIViHfS S7xD RIGH OF W1Y N 00 SGREES 2 27 w 3319 PEfiT TO SHE AOAAIrC PDRK RIYSR THENCE S 82 DEGRE85 47 35 S ALONG S11ZD AIVER 23208 FEES THENCE CQNTIkillZNli RLONG 5AID RIVYR S 7Z D6GREES 58 26 S 3760 FET TO 1 POIHT OH TffS EASTRLY 4INi 01 311ID LOT 12 TIiENCS CONTIMlYNG 1LONG 511ID RTVER 5 73 DQGR8S 00 I6 E 14796 FE1 THENCS LEAVZNG SAI RIIYR 5 13 DRCRBE9 2l 13 t 12590 PBTt THPNCE H 83 bEGREBS 03 38 W 876 YEYTt TFCENCE S 08 pBaR1C5 5T 24 W 3171 YYT THENCE S O1 DEGREES 32 47 8 134 PEB1 THENCe 5 l0 DECRE3 32 0 tt 2002 pgE THStSCE 07 aEGRE83 OS 3 1 2726 PEBT THENCE S 39 OEGREES 46 51 W 1060 FEST O A POSNT ON 1E8 tORTHStLY RICRC OF WAY OF SAIa COiJMTY R011D THENCE N 81 DECRELS 53 09 FT 1LONG SAID NORTfiERLY RICAT OP W1Y 3987 YitET THENCE CONTYHUIiSC ALONC SAID NOR173fiRLY RTCHS QF 47AY S 84 aGI2EES Ot 38 fi 14959 PfiET TFISNCE CONTINUYNG RLONC SAID NORTI3RLY RIGHT OF VnY S 83 DEGAES IO S6 W ia a 0 6 FEBS TO TiiB IRVE POSHT O3 86a2NNIDfG COt7NTY OP GARFZELD S1TS AY COGORAAD I fi 4aft AN 2 2011 CONSENT TO ASSIGNMENT SqNGINEF The BasaIt Water Conservancy District hereby consents to the foregoing Assignment subject to the terms and conditions of said Conract and the Districts receipt of all charges related thereto The Distzicts cansent to this Assignment is subject to the additional conditions set forth on Exhibit A attached hereto Dated this x2 day of January 2011 BASAIT ChrisEopher L Geiger Attorney for Basalt Wate Conservancy District Assigrtnrcnt No 77c Mary S LucianoChante Pej trr LLC CT WELL CONSTRUCTION AND TEST REPORT STATE OF COLORADO OFFICE OF THE STATE ENGINEER FOR OFFICE USE ONLY RECEIVEta OCT 14 2011 STA GINEFR APPROVAL GWS3I 91 03 1 WELL PERMIT NUMBER 74762 F 2 Owner Name s Branden Cohen Mailing Address 11258 Highway 133 City State Zip Carbondale Co 81623 Phone 4 3 WELL LOCATION AS DRILLED NW 1 4 SW 1 4 Sec 31 Twp 7 S Range 87 W 6th PM DISTANCES FROM SEC LINES ft from Sec line and ft from Sec line OR Easting 3 14 248 Northing 43 63 413 SUBDIVISION Ries Exemption LOT 3 BLOCK FILING UNIT STREET ADDRESS AT LOCATION 4 GROUND SURFACE ELEVATION ft DRILLING METHOD Air Rotary DATE COMPLETED 8 25 2011 TOTAL DEPTH 42 DEPTH COMPLETION 42 5 GEOLOGIC LOG 6 HOLE DIAMETER in FROM ft TO ft Depth Type of Material Size Color and Type 12 0 0 42 000 003 Dirt 003 020 Boulders Cobbles 020 042 Sand Gravel Cobbles 7 PLAIN CASING OD in Kind Wall Size From ft To ft 8 6 Steel 0 188 1 32 PERF CASING Screen Slot Size 8 6 Steel 0 188 32 42 Water Located 10 Remarks 8 Filter Pack Material Size Interval 9 Packer Placement Type Depth 10 GROUTING RECORD Material Amount Density Interval Placement Cement 8 sks 6 al sk 10 20 poured 11 DISINFECTION Type HTH Amt Used 3 oz 12 WELL TEST DATA O Check Box If Test Data Is Submitted On Supplemental TESTING METHOD Air Compressor Static Level 5 ft Date Time Measured 8 25 2011 Pumping Level Total ft Date Time Measured 8 25 2011 Test Remarks Production Rate 15 gpm Test Length 2 hours 13 I haveread the statements made hereinand know the contents thereof and that they are true to my knowledge Pursuant to Section 24 4 1 4 13 a CRS the making offalse statementsconstitutesperjuryintheseconddegreeandispunishableasaclass1misdemeanor CONTRACTOR Shelton Drilling Corp Phone 970 927 4182 Mailing Address P O Box 1059 Basa C 81621 Lic No 1095 Name Title Please Type or Print Wayne Shelton President Si 7V Date 8 26 2011 0 ER I I N A L FoRM No PUMP INSTALLATION AND TEST REPORT For otfce use on y G1N 32 STATE OF COLORADO FFICE OF THE STAT ENGINEER pq p Z 1313 Sherman St Room 821 Denver CO 80203 Main 303 866 3581 Fax 303 866 3589 dwroermitsonline state co us p 1 WELL PERMIT NUMB Rc74762 F qPRZWLOWNERINFORMATION NAME OF OWNER qTF 2 G Branden Cohen FTqT h MAILING ADDRESS c0 11258 Hwy 133 CITY STATE ZIP CODE Carbondale Co 81623 TELEPHONE area code 970 361 2195 3 WELL LOCATION AS DRILLE NW i14 SW 1 4 Sec 31 Twp r N or S Range 87 E or I W DISTANCES FROM SEC LINES 1704 ft from 0 N or S section line and 298 ft From L E or W section line SUBDIVISION LOT BLOCI FILING UNIT Optianal GPS Location GPS Unit must use the fo0owing settings Format must be UTM Units Easting 314247 must be meters batum must bs NAD83 Unit must be set to true AI Zone 12 or C Zone 13 Northing 4363413 TREET ADORESS AT WELL LOCATION 4 PUMP ATA Type Submersible Date Installed mm dd yyyy 05 02 20 13 Pump Manufacturer Grundfos Pump Model No 15SQE07 160 Dasign GPM 5 at RPM 000 Hp 3 4 Volts 230 Full Load Amps 7 6 Pump Intake Depth 40 Feet Drop Column Pipa Size Inches Kind of Drop Pipe Sch BO PVC ADDITIONAL NFORMATION FOR PUMPS GREATER THAN 50 GPM Turbine Driver Type Electric Engine Othar esi n Head feet Number of Sta es ShaR size inches 5 QTHER EQUIPMENT Alrllne Installed Yes No Orifice Depth R MonitorTube Installed Ye6 No Dopth n Flow Mete M g Meter Serial No Meter Readout jGallons housand Gallons cre feet Be innin E2sadin 6 TEST DATA chedc box if Test Data Is submitted on Supplemental Form Dale Total Well Depth 42 ft 7ime Static Level 5 ft Rate gpm 15 Date Measured 11 01 2011 Pum in Level it 6 9 7 DISINFECTION T e Chlorox Amt Used 2 Gallon 8 Water Qualit anal ais evaflable Yes x lVo If es lease aubmit wlth this report 9 Remarks A hand pump was installed in this well on 11 1 11 for temp water 10 I have read the statements made herein and know the contents thereof and they are true to my kncwledge By signing or entering my name I am certifying in accordance with Rule 17 4 of the Weter Well Construction Rules 2 CCR 402 2 The filing of a document that contains fatsa statements is a violation of aeclion 37 91 108 1 e C R S and is punishable by fines up to SOOD and or revocation of the contracting license Company Name Phone w area code Licene Number Samuelson Pump Com an Inc 970 945 6309 1050 Mailin Address P O ox 287 Glenwaod S rin s CO 81602 Sign or Enter Name and Tltle ate mm dd yyyy Raun E Samuelson Presldent 03 19 2014